Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis?

Introduction

Skeletally immature patient with adolescent idiopathic scoliosis (AIS) whose curves continue to progress despite bracing should be treated surgically. Vertebral body tethering (VBT) is a non-fusion, compression-based, growth preserving alternative to posterior spinal fusion (PSF) based on the concept of 'growth modulation' to prevent possible functional complications secondary to fusion while correcting scoliotic deformity. This review aims to shed light on the indications of VBT, short- and medium-term outcomes, describe the surgical technique and associated complications, and to compare its efficacy to that of PSF.

Methods

A review of peer-reviewed literature on VBT as a surgical technique, its indications, outcomes, complications, and comparison with other surgical interventions to correct AIS was conducted in December 2022.

Results

Indications remain controversial and mainly include stage of skeletal maturity based on radiographic markers, curve location, magnitude and flexibility, and presence of secondary curve. Assessment of VBT clinical success should not be restricted to improvement in radiographic parameters but should include functional results and patient-centered outcomes, improved body image and pain, and durability of outcomes. In contrast to fusion, VBT seems to be associated with preserved spinal growth, shorter recovery, potentially better functional outcomes, less motion loss but possibly less curve correction.

Discussion

Yet still, with VBT there exists a risk of overcorrection, construct breakage or failure of procedure which require revision and at times conversion to PSF. Patient and family preferences must be accounted for acknowledging gaps in knowledge, attributes and drawbacks of each intervention.

Magnetic resonance imaging of severe idiopathic club foot treated with one-week accelerated Ponseti (OWAP) technique

PURPOSE

This study aims to evaluate changes in tarsal bones relationship after the use of one week accelerated Ponseti method in the treatment of severe idiopathic clubfoot using MRI. We hypothesize that one-week accelerated Ponseti is at least as effective as standard techniques in achieving the desirable MRI parameters.

METHODS

This is a prospective study of 8 children with severe idiopathic clubfeet (Pirani 6) (4 unilateral and 4 bilateral) treated before the age of three months with one-week accelerated Ponseti technique, as described in a former study with minimum 2-year follow-up. The 8 corrected feet were compared with the 4 unilateral normal feet at clinical and radiological levels using a Pirani scoring system and an MRI, respectively.

RESULTS

Clinical results showed that Pirani score was 1.1 in the last follow up in comparison to Pirani 6 pretreatment (p < 0.05). MRI results indicated that the malleocalcaneal angle, axial malleocalcaneal index, coronal tibiocalcaneal angle, sagittal talocalcaneal angle, and talar head neck calcaneal rotation showed statistical difference between the two groups (p < 0.05). Sagittal malleocalcaneal index, sagittal tibiocalcaneal angle, talar head neck rotation related to talar body, and posterior calcaneal rotation showed no statistical difference between normal feet and clubfeet after correction (p value >0.05).

CONCLUSION

One-week accelerated Ponseti technique showed to be as effective and safe as other treatment methods through clinical and MRI follow up data. MRI role was to confirm the efficiency of this innovative accelerated technique, but not used as a routine follow up.

Active Apex Correction With Guided Growth Technique for Controlling Spinal Deformity in Growing Children: A Modified SHILLA Technique

STUDY DESIGN

A retrospective study.

OBJECTIVE

To determine if active remodulation in the apex of the curve is possible in scoliosis and kyphoscoliosis patients, using a modified SHILLA; active apex correction (APC) technique for guided growth.

METHOD

Twenty patients with either scoliosis or kyphoscoliosis underwent a modified SHILLA approach, where instead of apical fusion, APC was applied. In this modified technique, the most wedged vertebra was selected followed by insertion of pedicle screws in the convex side of the vertebrae above and below the wedged one. The convex and concave heights of the wedged and control vertebrae were recorded at the time of the surgery and at follow-up duration, both using computed tomography.

RESULTS

The wedged vertebra demonstrated in average a 17% (P = .00014) increase in the proportion of concave to convex heights ratio, whereas the control vertebra did not show any relative change in the wedged vertebra heights at the follow-ups.

CONCLUSION

APC, instead of apical fusion in SHILLA remodulates the apex vertebra, which may in turn help mitigate loss of correction on long term due to crankshafting and adding-on.

Growth-Friendly Implants With Rib Clawing Hooks as Proximal Anchors in Early-Onset Scoliosis

STUDY DESIGN

Retrospective study.

OBJECTIVES

This study retrospectively evaluates the outcome of the surgical treatment of early-onset scoliosis with proximal clawing rib fixation in hybrid growing-rod constructs. The study examines spinal deformity correction with spinal growth maintenance, and the complications associated with this technique.

METHOD

A hybrid rib construct surgery with serial lengthening was utilized for the treatment of 71 patients. Mean age at surgery was 66.6 months and mean time for follow-up was 43.9 months.

RESULTS

The coronal Cobb angle in patients fell from 63.1° preoperatively to 51.6° at the last follow-up, with a correction of 16.8%. The sagittal Cobb angle fell from 66.7° preoperatively to 38° at the last follow-up, with a correction of 42.6%. Coronal balance fell from 22.8° preoperatively to 22.3°, and sagittal balance fell from 35.4 mm preoperatively to 24.39 mm. T1-S1 spine height increased from 248.7 mm preoperatively to 282.4 mm, with a mean change of 1.13 cm per year. No neurological complications were detected.

CONCLUSION

Surgical management for early-onset scoliosis using proximal clawing rib fixation technique is a good choice in terms of safety, ease of placing the proximal anchors, ability to use more than one form of instrumentation, and a lower complication rate.

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BACKGROUND

Congenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week.

METHODS

This study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast.

RESULTS

Five patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8-150days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0-1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication.

CONCLUSIONS

The first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.

Active Apex Correction (Modified SHILLA Technique) Versus Distraction-Based Growth Rod Fixation: What Do the Correction Parameters Say?

Introduction

SHILLA and growth rods are two main surgical correction techniques for patients with early-onset scoliosis. There have been some comparative studies between the two techniques, where a comparison was made between deformity identifying characteristics such as Cobb angle, apical vertebral translation, coronal balance, spinal length gain, etc. However, the SHILLA procedure experiences loss of correction or the reappearance of deformity through crankshafting or adding-on (e.g., distal migration). The current study identifies a solution with a modified approach to SHILLA (which could help in dynamically remodulating the apex of the deformity and mitigating loss of correction) and presents comparative correction data against the long-established traditional growth rod system.

Methods

The active apex correction (APC) group consisted of 20 patients and the growth rod group consisted of 26 patients, both with the same inclusion and exclusion criteria. The APC surgical procedure involved a modified SHILLA technique, that is, insertion of pedicle screws in the convex side of the vertebrae above and below the wedged one for compression and absence of apical fusion.

Results

There were no statistical differences between the various spinal parameters (namely, Cobb angle, apical vertebral translation, sagittal balance, and spinal length gain) of the two groups. However, significant differences existed for coronal balance, which in part may have been due to differences in its pre-op value between the two groups.

Conclusions

APC and the traditional growth rod system showed similar deformity correction parameters at current follow-ups; however, the latter requires multiple surgeries to regularly distract the spine.

Active Apex Correction: An overview of the modified SHILLA technique and its clinical efficacy

OBJECTIVE

Provide current overview of Active Apex correction as a new technique for surgical management for Early Onset Scoliosis by dynamically remodulating the apex of the deformity and mitigate loss of correction and presents a comparative correction data against the long-established systems.

METHOD

Summary of the surgical technique and review of the existing retrospective data on APC surgical technique and its comparison against other existing techniques.

RESULTS

Retrospective clinical results showed the efficiency of the APC technique in active remodulation of the apex of the curve with lower incidence of implant related complications in comparison to SHILLA and Magnetically Controlled Growing Rods (MCGR). APC also showed similar results with traditional growing rods without the need for repeated distraction surgeries for 4 years.

CONCLUSION

Active Apex Control is safe and viable option in surgical management for Early Onset Scoliosis patients even in areas with limited resources.

Minimal invasive surgery techniques for patients with adolescent idiopathic and early onset scoliosis

OBJECTIVE

Provide an update on minimal invasive surgery (MIS) techniques for surgical management of pediatric spine.

METHODS

Minimal Invasive surgery for pediatric spine deformity has evolved significantly over the past decade. We include updated information about the surgical management of patients with adolescent idiopathic and Early Onset Scoliosis through MIS techniques. We take into consideration the implementation of this technique in Low-to-Middle Income Countries (LMICs).

RESULTS

Although MIS began as a technique in adult and degenerative spine, recent publications on MIS in pediatric spine cases report benefits of decreased blood loss and infection incidence, and cosmetic advantages from fewer incision numbers. Adoption of MIS techniques in pediatric spine can be facilitated with pre- and intraoperative use of pertinent medical systems.

CONCLUSION

With appropriate considerations and training, MIS is a safe procedure for pediatric spine correction surgery and can be applicable in LMICs.

Reliability and validity of the Arabic version of the Early Onset Scoliosis 24 Items Questionnaire (EOSQ-24)

Introduction: Early Onset Scoliosis (EOS) is a complex pathology that covers a variety of etiologies, with onset before the age of 10 years. Surgical treatment of EOS should have the objectives of fulfilling maximum pulmonary function, spine length, with minimal hospitalizations, complications, and family burden. Radiographic parameters are an important standard in assessing treatment outcomes. However, the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) was developed to measure the wider dimensions of outcomes involving the quality of life of patients and caregivers post-treatment. The aim of this study was to evaluate the validity and reliability of culturally adapted Arabic version of the EOSQ-24.

Methods: Translation and cross-cultural adaptation, based on published guidelines, were performed on the original English EOSQ-24 by a committee. The Arabic version of EOSQ-24 was applied to the caregivers of all 58 EOS patients who were treated surgically after signing a consent form. Reliability was assessed using Cronbach’s α and item-total statistics for the whole questionnaire initially and for the each domain separately. Data quality was assessed by mean, median, percentage of missing data, ceiling and floor effects. Discriminative validity was examined using non parametric tests.

Results: The response for all items was excellent with only 1.7% (0–1) of responses missing. The floor effect ranged from 0% to 36.2% of patients and the ceiling effect ranged from 0 to 46.6%. Cronbach’s α test reliability was found excellent (0.919), as was the internal consistency of all domains, with Cronbach α ranging from 0.903 to 0.918. Corrected item-total correlations were good for all domains (>0.3). Only one item (Question 21) showed low corrected item-total correlations (r = 0.222). However, Cronbach’s α did not increase significantly when this item was deleted (0.920).

Conclusion: The first adapted Arabic version of EOSQ-24 is found to have good validity and reliability, and it can be used to assess children in Arab societies with EOS.

Treatment of spinal deformity associated with myelomeningocele in young children with the use of the four-rib construct

Surgery for myelomeningocele spinal deformity is accompanied by a high rate of complications. These include infection, pathological skin breakage, instrumentation failure, and neurological deterioration. The four-rib construct associated with the percutaneous technique in immature children with myelomeningocele and spinal deformity is introduced. The four-rib construct serves to correct for deformity and to allow for growth, with minimal complications. The study was small and retrospective, a level four case series. The results of four patients who underwent the four-rib construct surgery in 2008 and 2009 was revised. All four were nonambulatory, skeletally immature children, not previously corrected by bracing, with the progressive spinal deformity associated with myelomeningocele affecting their sitting position. Furthermore, the research protocol was approved by our institutional review board. Three patients were females and one was male. Two cases of kyphoscoliosis, one of kyphosis, and one of scoliosis. Age at the time of the initial procedure ranged between 64 and 82 months, with a mean age of 70 months. Follow-up time after surgery ranged from 24 to 39 months, with a mean of 31 months. Preoperatively, deformity angles were severe, averaging 55° for thoracic scoliosis, 67° for thoracolumbar scoliosis, and 85° for thoracolumbar kyphosis. Surgery mitigated the deformities markedly. Postoperative angles measured were 42° for thoracic scoliosis, 21° for thoracolumbar scoliosis, and 45° for thoracolumbar kyphosis. These observations indicate significant reductions in spinal deformity, by 24, 69, and 48%, respectively. In total, 14 procedures were performed: four initial implants and 10 lengthening and exchange procedures. There were no intraoperative complications. The postoperative complications that did arise consisted of two instances of skin breakage, one distal iliac screw dislodgement, and one shunt displacement. Significantly, no proximal fixation dislodgement, deep-seated infection, or damage in the pathological skin were detected. The four-rib construct technique can be considered as a potential surgical option in (powered by Editorial Manager and Preprint Manager; Aries Systems Corporation) treating spinal deformity associated with myelomeningocele, but still more patients with long term follow-up are needed to prove the efficacy of this procedure. The four-rib construct is simple, minimally invasive, and does not exclude alternative treatment. Moreover, the incidence of complications associated with the four-rib construct compares favorably with other growth techniques.

Surgical correction of severe Sprengel deformity to allow greater postoperative range of shoulder abduction

BACKGROUND

Although the Sprengel deformity is relatively uncommon, several surgical procedures have been described for its treatment. In this article, we will report the outcome of a certain surgical technique targeted at the management of children with severe Sprengel deformity. The technique aims to increase their postoperative range of shoulder abduction.

METHODS

We reviewed the results of 15 shoulders operated in 11 patients. The children had severe congenital elevated scapula (9 Cavendish IV and 6 Cavendish III) and were all with less than 90 degrees of preoperative shoulder abduction. The mean age at surgery was 64 months, the mean length of follow-up was 36.5 months, and the mean age at the last examination was 95 months. Surgery included fixation of the upper scapula to the lower thoracic spine. As such, we used a stout suture with lateral displacement of the inferior tip of the scapula and immediate postoperative mobilization with physiotherapy. None of the children underwent clavicular osteotomy. Operative results were evaluated on both functional and cosmetic bases.

RESULTS

Appearance improved according to the Cavendish scale. Postoperatively, 7 shoulders were graded as Cavendish I and the other 8 as Cavendish II. The range of motion improved significantly by comparing the preoperative and postoperative range of abduction. The mean for postoperative abduction was 139 degrees, with an absolute range of 90 to 170 degrees. Three shoulders had winging of the scapula. There was temporary postoperative upper arm numbness in 1 shoulder. Four patients had a cosmetically unattractive scar because of keloid formation. All families were satisfied with the results (9 very good and 6 good).

CONCLUSIONS

We have described a procedure for severe Sprengel deformity up to 15 years of age followed by immediate physiotherapy. This procedure not only results in the caudal displacement of the scapula, but it also corrects the scapular and glenoid plane (with limited procedures). Accordingly, it offers an improvement, both functionally and cosmetically.

LEVEL OF EVIDENCE

Level IV therapeutic study.